I read with interest the paper entitled “Cost minimization analysis of laparoscopic sacral colpopexy and total vaginal mesh” by Drs Christopher F. Maher and Luke B. Connelly. The paper focused on cost containment for the treatment of uterine prolapse. I noticed that the authors considered laparoscopy vs the total mesh vaginal approach. This very well-done study did not mention the inexpensive minilaparotomy approach.

I presented the minilaparotomy approach for sacral cervicopexy followed by a slide presentation online ( ObGyn.net ) entitled “Surgical treatment of uterine procidentia” under the auspices of the American Association of Gynecologic Laparoscopists 33rd annual meeting in November 2004.

I used an elastic retractor placed inside the abdomen through a 5-cm transverse suprapubic incision. Exposure of the sacral peritoneum is easy to accomplish as the prolapsed uterus is not blocking the view. The peritoneum in front of the promontory is open; a suture is placed in the promontory ligament and tested for its holding strength. Supracervical hysterectomy is then performed. Prior to the amputation, the fundus of the uterus is pulled upward and anterior to aid in the next step of the cul-de-sac obliteration. A polypropylene hammock is threaded using the previously placed sutures and tied at the promontory. This is followed by amputation of the uterus and ablation of the endocervical canal. The hammock caudal end is tied at the cervical stump near the uterosacral ligaments. The cervical stump and the hammock are covered with peritoneum. The parietal peritoneum is closed and the elastic retractor is removed. The incision gives sufficient exposure to perform the Burch procedure.

The technique was successfully used with minor modifications by Dr Martin Castillo Mendoza from Peru, Dr Vicente Sola et al from Chile, and Dr Alan D. Garely from the United States. I agreed with the authors of this fine article that “it is now imperative that clinicians include dollar cost of surgical interventions as a vital part of our decision making process.” Minilaparotomy is a reproducible, efficient, and inexpensive minimal access surgery for the treatment of uterine prolapse that does not compromise quality or results.